What are the indications for a Gastrointestinal (GI) referral for fecal incontinence?

From the Guidelines

A gastroenterology (GI) referral is crucial for bowel incontinence after initial management attempts have failed, as it significantly impacts quality of life and may indicate serious underlying conditions requiring specialized management. Begin with conservative measures including fiber supplementation (psyllium 1 tablespoon daily), anti-diarrheal medications like loperamide (2mg before meals if diarrhea is present), and pelvic floor exercises, as suggested by 1. If these interventions don't improve symptoms within 4-6 weeks, refer to gastroenterology for specialized evaluation. The GI specialist can perform comprehensive testing including anorectal manometry, endoanal ultrasound, and defecography to identify underlying causes such as sphincter damage, rectal prolapse, or neurological issues, as outlined in 1 and 1.

Some key considerations for initial management include:

• A meticulous characterization of the bowel habits, circumstances surrounding FI, and prior treatment for FI, as emphasized in 1
• Among patients with diarrhea, a careful dietary history to identify ingestion of poorly absorbed sugars and/or caffeine followed by a trial of elimination
• For diarrhea, starting with loperamide (2 mg) generally taken 30 minutes before breakfast and titrated as necessary up to 16 mg daily, as recommended in 1
• Fiber supplementation can be used to improve stool consistency and reduce diarrhea-associated FI, as noted in 1

The GI specialist may recommend advanced treatments including biofeedback therapy (typically 6-8 sessions), sacral nerve stimulation, or surgical options for refractory cases. When making the referral, include details about symptom duration, severity, prior treatments attempted, and any risk factors like obstetric trauma, prior surgeries, or neurological conditions. Prompt referral is important as bowel incontinence significantly impacts quality of life, as highlighted in 1.

From the Research

GI Referral for Bowel Incontinence

• Fecal incontinence (FI) is a common and debilitating condition that can be managed through various treatment options 2, 3, 4, 5, 6.
• The initial evaluation of FI requires a focused history and physical examination, and recording patient symptoms using a standard diary or questionnaire can help document symptoms and response to treatment 6.
• Conservative approaches, including dietary modifications, medications, muscle-strengthening exercises, and biofeedback, have been shown to provide short-term benefits 3, 5.
• Combination therapy with biofeedback, loperamide, and stool-bulking agents is effective for the treatment of FI in women 5.
• Invasive procedures, including sacral nerve stimulation, may be considered when conservative therapies are ineffective, but they are associated with complications and lack randomized, controlled trials 3, 4.
• Other treatment options include pelvic floor muscle strengthening with or without biofeedback, devices placed anally or vaginally, and surgery, including sacral neurostimulation, anal sphincteroplasty, and colonic diversion 4, 6.

Treatment Options

• Sacral nerve stimulation is both effective and durable and is now the most popular of the invasive techniques 4.
• Injection of bulking agents, such as dextranomer microspheres in non-animal stabilized hyaluronic acid (NASHA Dx), has shown significant improvement in incontinence scores and frequency of incontinence episodes 3.
• Radiofrequency energy delivery to the anal canal and percutaneous tibial stimulation are either less effective or their evaluation has been handicapped by suboptimal study designs 4.
• Stem cell therapy is a potentially exciting approach, which is in its infancy 4.

Patient Care

• Fewer than 30% of women with FI seek care, and lack of information about effective solutions is an important barrier for both patients and health care professionals 6.
• The symptom improvement was associated with improved fecal consistency, reduced urgency, and increased rectal sensory thresholds 5.
• FI negatively affects quality of life and mental health and is associated with increased risk of nursing home placement 6.